Cardiac Risk Research Articles

Incidentally Induced Atrial Fibrillation During Programmed Electrical Stimulation in Patients With Depressed Left Ventricular Systolic Function After an Acute Myocardial Infarction.

The aim of this study was to investigate the clinical implication of incidentally induced atrial fibrillation (AF) during programmed electrical stimulation (PES) in patients with left ventricular systolic dysfunction (≤40%) after an acute myocardial infarction (MI). In this study, we included 231 patients from the Cardiac Arrhythmias and RIsk Stratification after Myocardial InfArction (CARISMA) study with left ventricular ejection fraction ≤40% and no prior history of AF. These patients underwent PES 6 weeks post-MI as part of the study protocol. Patients all received an implantable cardiac monitor (ICM) 3-21 days post-MI and were continuously monitored for cardiac arrhythmias for 2 years. Induction of AF was unwanted but reported if this incidentally occurred. A total of 61 patients (26%) developed AF within 2 years of follow-up, in which n = 10 (29%) had incidental AF during PES at baseline. The overall risk of AF was not significantly increased in patients with incidental AF (n = 34) during PES compared to patients without incidental AF (n = 197) (HR 1.6 [0.9-3.0], p = 0.14). The risk of bradyarrhythmia (HR = 0.2 [0.0-1.2], p = 0.07), ventricular arrhythmias (HR = 0.7 [0.1-5.8], p = 0.77), and major cardiovascular events (MACE) (HR 0.5 [0.2-1.7], p = 0.28) was not significantly different in patients with versus without incidental AF. Incidentally induced AF during PES in post-MI patients with reduced LVEF was not significantly associated with a higher risk of long-term atrial fibrillation, other cardiac arrhythmias, or major cardiac events. NCT00145119.

Triglyceride-HDL index as a predictor of post-stroke outcomes: A retrospective analysis of 6,235 ischemic stroke patients from the Qatar Stroke Database

Objectives: In this study, we explored the Qatar stroke database to study the independent effect of sex- specific TG-HDL index on neurologic and cardiovascular outcomes following stroke in a predominantly Arab and Southeast Asian population. Methods: All patients admitted with acute ischemic stroke between 2014-2022 were included. TG-HDL index on admission was calculated and patients were stratified into sex-specific quartiles. We studied the 90-day modified Rankin Score (mRS), and 1-year major cardiac adverse events (MACE). Multivariate linear and binary logistic regression analyses were performed to identify the independent effect of TG-HDL index on short- and long-term outcomes. Results: A total of 6,235 stroke patients were identified. Overall, mean age was 55±13 years; 5,122 patients (82%) male; 1,989(32%) Arab; 1,628(26%) BMI ≥30; 3,526 (57%) diabetes mellitus; 4,598 (74%) hypertension, 3,158 (51%) dyslipidemia, and 1,876 (30%) smokers. The median TG levels were 1.5 (1.0-2.3), HDL levels 1.0 (0.8-1.2), and TG-HDL index was 1.5 (1.0-2.3). On long term follow-up, 120 (2%) had a recurrent stroke, 314 (5.1%) had MACE, 38 (0.6%) had post-stroke MI, and 37 (0.6%) had post-stroke cardiac revascularization procedures. On multivariate analyses, higher sex-specific TG-HDL index was independently associated with lower adjusted odds of severe stroke and lower inpatient mortality, and higher 1-year adjusted odds of post-stroke MI (p<0.05). Conclusion: TG-HDL was strongly associated with in-patient mortality and long-term post-stroke cardiovascular outcomes but not long-term stroke recurrence. Our finding of an independently increased 1-year risk of post-stroke MI with higher TG-HDL index may warrant consideration of this index as a cardiac risk stratification tool for stroke patients.

Factors affecting adherence to recommendations on pre-operative cardiac testing: A cohort study.

Cardiac risk evaluation prior to noncardiac surgery is fundamental to tailor peri-operative management to patient's estimated risk. Data on the degree of adherence to guidelines in patients at cardiovascular risk in Europe and factors influencing adherence are underexplored. The aim of this analysis was to describe the degree of adherence to [2014 European Society of Cardiology (ESC)/European Society of Anaesthesiology (ESA) guidelines] recommendations on rest echocardiography [transthoracic echocardiography (TTE)] and to stress imaging prior to noncardiac surgery in a large European sample and to assess factors potentially affecting adherence. Secondary analysis of a multicentre, international, prospective cohort study (MET-REPAIR). Twenty-five European centres of all levels of care that enrolled patients between 2017 and 2020. With elevated cardiovascular risk undergoing in-hospital elective, noncardiac surgery. (Non)adherence to each pre-operative TTE and stress imaging recommendations classified as guideline-adherent, overuse and underuse. We performed descriptive analysis. To explore the impact of patients' sex, age, geographical region, and hospital teaching status, we conducted multivariate multinominal regression analysis. Out of 15 983 patients, 15 529 were analysed (61% men, mean age 72 ± 8 years). Overuse (conduction in spite of class III) and underuse (nonconduction in spite of class I recommendation) for pre-operative TTE amounted to 16.6% (2542/15 344) and 6.6% (1015/15 344), respectively. Stress imaging overuse and underuse amounted to 1.7% (241/14 202) and 0.4% (52/14 202) respectively. Male sex, some age categories and some geographical regions were significantly associated with TTE overuse. Male sex and some regions were also associated with TTE underuse. Age and regions were associated with overuse of stress imaging. Male sex, age, and some regions were associated with stress imaging underuse. Adherence to pre-operative stress imaging recommendation was high. In contrast, adherence to TTE recommendations was moderate. Both patients' and geographical factors affected adherence to joint ESC/ESA guidelines. NCT03016936.

Benefits of Cardiac Biomarkers and Stress ECG in Cardiac Risk Stratification of Patients Scheduled for Non-Cardiac Surgery

Benefits of Cardiac Biomarkers and Stress ECG in Cardiac Risk Stratification of Patients Scheduled for Non-Cardiac Surgery

Surgical Outcomes for Patients With Trisomy 21 and Hirschsprung's Disease: An NSQIP-Pediatric Study

IntroductionPrevious studies have demonstrated worse outcomes for Hirschsprung's disease (HD) procedures in Trisomy 21 (T21) patients. Using a large national database, we sought to investigate surgical outcomes in HD patients with T21 compared to non-T21 patients. MethodsWe utilized the deidentified National Surgical Quality Improvement Program Pediatric database from 2012 to 2021. Using International Classification of Diseases, Ninth Revision codes, children <18 y old with HD were included and stratified by T21 diagnosis. Demographics, Current Procedural Terminology codes, case characteristics, length of hospital stay, and postoperative complications were analyzed. ResultsOf 3456 HD patients, 12.0% (n = 413) patients had a concurrent diagnosis of T21. Pull-through (PT) procedures accounted for 54.9% of surgeries (n = 1896), of which 10.0% (n = 189) had T21. T21 patients who underwent PT had a younger gestational age (P < 0.0001), cardiac risk factors (P < 0.0001), hematologic disorders (P < 0.0001), higher American Society of Anesthesiologists class (P < 0.0001), and were older at their index operation (P = 0.03). Though operative times were similar, T21 patients had a longer total length of stay (P = 0.0263), postoperative length of stay (P = 0.0033), and more unplanned reoperations (P = 0.0094). Though only significant in unadjusted analyses, T21 patients had more postoperative complications after PT (P = 0.0034), specifically deep surgical site infections (P = 0.009), organ/space surgical site infections (P = 0.004), wound disruption (P < 0.001), and sepsis (P = 0.025). ConclusionsWe confirm significant differences exist between T21 and non-T21 patients undergoing HD procedures, particularly increased total length of stay, postoperative length of stay, and unplanned reoperations. Understanding these differences will lead to more optimal treatment plans for this unique patient population.

Effects of multiple protection model in the operating room on physiological stress and risk events in patients undergoing coronary artery stent implantation

ObjectiveTo analyze the impact of multiple protection model in the operating room on patients’ physiological stress and risk events after coronary artery stent implantation (CASI).MethodsDuring October 2021 to October 2022, 150 patients with coronary heart disease (CHD) were picked as the research subjects, all of whom underwent CASI. The clinical data were retrospectively analyzed, and the patients were divided into two groups according to different nursing methods, with 75 cases in each group. Patients in the intervention group received multiple protection model intervention in the operating room, and the patients in the control group adopted conventional care model. The patient satisfaction with nursing, postoperative recovery, psychological stress scores, physiological stress indicators, and adverse cardiac risk events were recorded.ResultsPatients in the intervention group had much higher percentage of the patient satisfaction with nursing than those in the control group (P < 0.05). The time to get out of bed and hospital stay was significantly shorter and the 6-min walking distance was markedly longer in the intervention group than the control (P < 0.05). The Hamilton Anxiety (HAMA) scale and Hamilton Depression (HAMD) scale score of patients in two groups were sharply decreased after the intervention (P < 0.05), which were strongly lower in the intervention group than the control (P < 0.001). After the intervention, the heart rate, cortisol and epinephrine of patients were all sensibly elevated in two groups (P < 0.05), which were all memorably lower in the intervention group than the control (P < 0.001). The incidence of adverse cardiac risk events in the intervention group was 5.33%, which was dramatically lower than 16.00% in the control group (P < 0.05).ConclusionThe application of multiple protection model in the operating room on patients undergoing coronary stent implantation promoted postoperative recovery, reduced patients' psychological and physiological stress, maintained blood pressure and other vital signs, reduced the incidence of adverse cardiac risk events, and improved the patient satisfaction with nursing.

Validation of activity trackers to estimate energy expenditure in older adults with cardiovascular risk factors.

To compare different types of activity trackers recording physical activity energy expenditure (PAEE) and examine their criterion validity against indirect calorimetry (IC) as the gold standard in adults over 60 years of age with a special focus on women with cardiovascular risk. Synchronous registrations of PAEE were performed with up to four different devices to determine criterion validity against IC while participants performed a protocol of simulated activities in a laboratory setting. Thirty-four participants (25 women, 9 men) with at least a light cardiac risk performed a protocol of simulated activities in a laboratory setting (daily living activities, cycle ergometer test). PAEE was simultaneously assessed by IC, two research-grade activity trackers (ActiGraph-wGT3X-BT and Actiheart-4) and two consumer-level activity trackers (OMRON pedometer and Fitbit Charge-3). Tracker-derived PAEE was compared with PAEE calculated from IC descriptively and by Bland-Altman plots. The ActiGraph (0.7 ± 0.4 kcal/min), the Actiheart (1.1 ± 0.6 kcal/min) and the OMRON (0.8 ± 0.6 kcal/min) underestimated, while the Fitbit (3.4 ± 1.2 kcal/min) overestimated PAEE compared to IC-PAEE (2.0 ± 0.5 kcal/min). The Bland-Altman limits of agreement (LoA) against IC were +0.5/+2.2 kcal/min for the ActiGraph, -0.3/+2.1 kcal/min for the Actiheart, -3.7/+1.0 kcal/min for the Fitbit, and -0.5/+2.9 kcal/min for the OMRON. The magnitude of the deviation varied considerably depending on the activity (e.g. walking, cleaning, cycle ergometer test). The research-grade activity trackers estimated PAEE with higher validity than the commercially available activity trackers. The partly very wide LoA have to be critically considered when assessing PAEE in the context of health service research, as individual Physical Activity behaviour may be under- or overestimated.

Impact of multiple comorbidities on long-term mortality in older patients following transcatheter aortic valve replacement

BackgroundOlder candidates for transcatheter aortic valve replacement (TAVR) frequently present with both cardiac and noncardiac comorbidities. There are few risk scores that evaluate a wide range of comorbidities. MethodsPatients who underwent TAVR for severe aortic stenosis were retrospectively evaluated. A new prediction model (Cardiac and nonCardiac Comorbidities risk score: 3C score) was determined based on coefficient in the multivariate Cox regression analysis for two-year all-cause mortality. C-statistics were assessed to compare the predictive abilities of the 3C score, the Charlson Comorbidities Index (CCI) score, the European System for Cardiac Operative Risk Evaluation (EuroSCORE) II, and the Model for End-stage Liver Disease eXcluding International normalized ratio (MELD-XI) score. ResultsThe present study included 226 patients (age, 86 ± 5 years; males, 38 %). The values of the CCI score, EuroSCORE II, and MELD-XI score were 2 (1–3), 3.36 (2.12–4.58), and 5.35 (3.05–8.55), respectively. Multivariate Cox regression analysis identified two cardiac (left ventricular ejection fraction [LVEF] <40 % [2 points]; pulmonary hypertension [1 point]) and three noncardiac comorbidities (hepatobiliary system impairment [3 points]; estimated glomerular filtration rate <30 ml/min/1.73 m2 [1 point]; cachexia [1 point]). The C-statistics of the 3C score, EuroSCORE II, MELD-XI score, and CCI score were 0.767 (0.666–0.867), 0.610 (0.491–0.729), 0.580 (0.465–0.696), and 0.476 (0.356–0.596), respectively (p < 0.001). ConclusionsAmong cardiac and noncardiac comorbidities, special attention should be given to hepatobiliary system impairment and reduced LVEF in older patients following TAVR. The 3C score may contribute to the risk stratification.

Impairment of Cognitive Function Increases Mortality Risk in Relation to Cardiac Sympathetic Denervation and Renal Dysfunction in Patients With Systolic Heart Failure.

In contrast to the well-known prognostic values of the cardiorenal linkage, it remains unclear whether impaired cognitive function affects cardiac prognosis in relation to cardiac sympathetic innervation and renal function in patients with heart failure (HF). A total of 433 consecutive HF patients with left ventricular ejection fraction (LVEF) <50% underwent the Mini-Mental State Examination (MMSE) and a neuropsychological test for screening of cognition impairment or subclinical dementia. Following metaiodobenzylguanidine (MIBG) scintigraphy, patient outcomes with a primary endpoint of lethal cardiac events (CEs) were evaluated for a mean period of 14.8 months. CEs were documented in 84 HF patients during follow-up. MMSE score, estimated glomerular filtration rate (eGFR) and standardized heart-to-mediastinum ratio of MIBG activity (sHMR) were significantly reduced in patients with CEs compared with patients without CEs. Furthermore, overall multivariate analysis revealed that these parameters were significant independent determinants of CEs. The cutoff values of MMSE score (<26), sHMR (<1.80) and eGFR (<47.0 mL/min/1.73 m2) determined by receiver operating characteristic (ROC) analysis successfully differentiated HF patients at more increased risk for CEs from other HF patients. Impairment of cognitive function is not only independently related to but also synergistically increases cardiac mortality risk in association with cardiac sympathetic function and renal function in patients with HF.

Perivascular Fat: A Novel Risk Factor for Coronary Artery Disease.

Perivascular adipose tissue (PVAT) interacts with the vascular wall and secretes bioactive factors which regulate vascular wall physiology. Vice versa, vascular wall inflammation affects the adjacent PVAT via paracrine signals, which induce cachexia-type morphological changes in perivascular fat. These changes can be quantified in pericoronary adipose tissue (PCAT), as an increase in PCAT attenuation in coronary computed tomography angiography images. Fat attenuation index (FAI), a novel imaging biomarker, measures PCAT attenuation around coronary artery segments and is associated with coronary artery disease presence, progression, and plaque instability. Beyond its diagnostic capacity, PCAT attenuation can also ameliorate cardiac risk stratification, thus representing an innovative prognostic biomarker of cardiovascular disease (CVD). However, technical, biological, and anatomical factors are weakly related to PCAT attenuation and cause variation in its measurement. Thus, to integrate FAI, a research tool, into clinical practice, a medical device has been designed to provide FAI values standardized for these factors. In this review, we discuss the interplay of PVAT with the vascular wall, the diagnostic and prognostic value of PCAT attenuation, and its integration as a CVD risk marker in clinical practice.

Safety of proteasome inhibitor drugs for the treatment of multiple myeloma post-marketing: a pharmacovigilance investigation based on the FDA adverse event reporting system

ABSTRACT Background The use of proteasome inhibitors (PIs), namely Bortezomib and Carfilzomib, revolutionized multiple myeloma (MM) treatment. Understanding their distinct adverse event (AE) profiles aids in tailored treatment plans. Research design and methods We analyzed FDA Adverse Event Reporting System (FAERS) data (Q1 2012-Q4 2023) for Bortezomib and Carfilzomib, utilizing reporting odds ratio (ROR), proportional reporting ratio (PRR), and Bayesian confidence propagation neural network (BCPNN). Results FAERS yielded 19,720 Bortezomib and 12,252 Carfilzomib AE reports. Males aged 45–65 exhibited higher AE susceptibility. Common AE systems included Infections, Nervous System Disorders, Blood Disorders, General Disorders, Cardiac Disorders, and Renal Disorders. New Bortezomib signals were sepsis and colitis. Carfilzomib exhibited elevated cardiac and renal toxicity but reduced peripheral neuropathy and thrombocytopenia. Conclusions FAERS analysis revealed new AE signals (sepsis, colitis) for Bortezomib and highlighted Carfilzomib’s heightened cardiac and renal risks compared to Bortezomib. Balancing PIs’ benefits and risks is crucial for clinical decision-making.

Open-bore MRI Scanner Assessment of Epicardial Adipose Tissue after Bariatric Surgery: A Pilot Study.

The recognition of epicardial adipose tissue (EAT) as a cardiac risk factor has increased the interest in strategies that target cardiac adipose tissue. The effect of bariatric and metabolic surgery (BMS)-induced weight loss on EAT volume was evaluated in this study. Fifteen bariatric patients, with (MS) or without (wMS) Metabolic Syndrome, underwent magnetic resonance imaging (MRI) using an open-bore scanner to assess EAT volume, visceral adipose tissue (VAT) thickness, and other cardiac morpho-functional parameters at baseline and 12 months after BMS. Nine patients underwent laparoscopic sleeve gastrectomy (LSG), and 6 patients underwent Roux-en-Y Gastric Bypass (RYGBP). EAT volume significantly decreased in all the patients 12 months post-BMS from 91.6 cm3 to 67.1 cm3; p = 0.0002 in diastole and from 89.4 cm3 to 68.2 cm3; p = 0.0002 in systole. No significant difference was found between the LSG and RYGBP group. Moreover, EAT volume was significantly reduced among wMS compared with MS. In particular, EAT volume in diastole was significantly reduced from 80.9 cm3 to 54.4 cm3; p = 0.0156 in wMS and from 98.3 cm3 to 79.5 cm3; p = 0.031 in MS. The reduction was also confirmed in systole from 81.2 cm3 to 54.1 cm3; p = 0.0156 in wMS and from 105.7 cm3 to 75.1 cm3; p = 0.031 in MS. Finally, a positive correlation was found between EAT loss, BMI (r = 0.52; p = 0.0443) and VAT (r = 0.66; p = 0.008) reduction after BMS. These findings suggest that EAT reduction may be a fundamental element for improving the cardio-metabolic prognosis of bariatric patients. Moreover, this is the first study performed with an open-bore MRI scanner to measure EAT volume.

Imatinib‑ and ponatinib‑mediated cardiotoxicity in zebrafish embryos and H9c2 cardiomyoblasts.

Tyrosine kinase inhibitors (TKIs) offer targeted therapy for cancers but can cause severe cardiotoxicities. Determining their dose‑dependent impact on cardiac function is required to optimize therapy and minimize adverse effects. The dose‑dependent cardiotoxic effects of two TKIs, imatinib and ponatinib, were assessed in vitro using H9c2 cardiomyoblasts and in vivo using zebrafish embryos. In vitro, H9c2 cardiomyocyte viability, apoptosis, size, and surface area were evaluated to assess the impact on cellular health. In vivo, zebrafish embryos were analyzed for heart rate, blood flow velocity, and morphological malformations to determine functional and structural changes. Additionally, reverse transcription‑quantitative PCR (RT‑qPCR) was employed to measure the gene expression of atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP), established markers of cardiac injury. This comprehensive approach, utilizing both in vitro and in vivo models alongside functional and molecular analyses, provides a robust assessment of the potential cardiotoxic effects. TKI exposure decreased viability and surface area in H9c2 cells in a dose‑dependent manner. Similarly, zebrafish embryos exposed to TKIs exhibited dose‑dependent heart malformation. Both TKIs upregulated ANP and BNP expression, indicating heart injury. The present study demonstrated dose‑dependent cardiotoxic effects of imatinib and ponatinib in H9c2 cells and zebrafish models. These findings emphasize the importance of tailoring TKI dosage to minimize cardiac risks while maintaining therapeutic efficacy. Future research should explore the underlying mechanisms and potential mitigation strategies of TKI‑induced cardiotoxicities.

Effect of early administration of tetracosactide on mortality and host response in critically ill patients requiring rescue surgery: a sensitivity analysis of the STOPSHOCK phase 3 randomized controlled trial

BackgroundUndifferentiated shock is recognized as a criticality state that is transitional in immune-mediated topology for casual risk of lethal microcirculatory dysfunction. This was a sensitivity analysis of a drug (tetracosactide; TCS10) targeting melanocortin receptors (MCRs) in a phase 3 randomized controlled trial to improve cardiovascular surgical rescue outcome by reversing mortality and hemostatic disorders.MethodsSensitivity analysis was based on a randomized, two-arm, multicenter, double-blind, controlled trial. The Naïve Bayes classifier was performed by density-based sensitivity index for principal strata as proportional hazard model of 30-day surgical risk mortality according to European System for Cardiac Operative Risk Evaluation inputs-outputs in 100 consecutive cases (from August to September 2013 from Emilia Romagna region, Italy). Patients included an agent-based TCS10 group (10 mg, single intravenous bolus before surgery; n = 56) and control group (n = 44) and the association with cytokines, lactate, and bleeding-blood transfusion episodes with the prior-risk log-odds for mortality rate in time-to-event was analyzed.ResultsThirty-day mortality was significantly improved in the TCS10 group vs. control group (0 vs. 8 deaths, P < 0.0001). Baseline levels of interleukin (IL)-6, IL-10, and lactate were associated with bleeding episodes, independent of TCS10 treatment [odds ratio (OR) = 1.90, 95% confidence interval (CI) 1.39–2.79; OR = 1.53, 95%CI 1.17–2.12; and OR = 2.92, 95%CI 1.40–6.66, respectively], while baseline level of Fms-like tyrosine kinase 3 ligand (Flt3L) was associated with lower bleeding rates in TCS10-treated patients (OR = 0.31, 95%CI 0.11–0.90, P = 0.03). For every 8 TCS10-treated patients, 1 bleeding case was avoided. Blood transfusion episodes were significantly reduced in the TCS10 group compared to the control group (OR = 0.32, 95%CI 0.14–0.73, P = 0.01). For every 4 TCS10-treated patients, 1 transfusion case was avoided.ConclusionsSensitivity index underlines the quality target product profile of TCS10 in the runway of emergency casualty care. To introduce the technology readiness level in real-life critically ill patients, further large-scale studies are required.Trial registrationEuropean Union Drug Regulating Authorities Clinical Trials Database (EudraCT Number: 2007-006445-41).

Machine Learning Models for Predicting Heart Failure: Unveiling Patterns and Enhancing Precision in Cardiac Risk Assessment

Purpose This study aims to evaluate the efficacy of various machine learning models in predicting heart failure incidence using medical data, focusing on the innovative aspect of a novel dataset. Unlike previous studies that predominantly examined features such as smoking status or age, this research explores novel features. The primary challenge addressed is the utilization of these new features, coupled with machine learning techniques, to accurately diagnose heart failure. Methods Five machine learning models, including logistic regression, support vector classifier, decision tree classifier, random forest classifier, and K-nearest neighbors, were applied to analyze medical data from a dataset comprising over 900 individuals. The dataset encompasses diverse parameters such as age, sex, chest pain severity, blood pressure, cholesterol levels, blood sugar levels, and electrocardiogram results, introducing a novel approach to feature selection. Results The evaluation of machine learning models unveiled varying performances in predicting heart failure. Logistic regression and support vector classifier exhibited the highest accuracy of 88%, followed by the decision tree classifier (below 85%), random forest classifier (84%), and K-nearest neighbors (82%). Additionally, the analysis revealed a balanced dataset distribution and highlighted sex-based disparities in heart failure incidence, along with significant correlations with factors such as age, chest pain severity, blood glucose levels, and physical activity. Conclusions The findings underscore the potential of integrating multiple machine learning models for early detection of heart failure, leveraging the inclusion of novel features in the dataset. However, careful model selection is crucial to account for discrepancies in accuracy among different models, emphasizing the importance of tailoring approaches based on specific project requirements.

Factors Affecting the Effectiveness of DIBH (Deep Inspiratory Breath Hold) in Patients with Left Breast Cancer: A Narrative Review

Deep Inspiratory Breath Hold (DIBH) has become a valuable technique in left-breast cancer radiotherapy, offering the possibility to reduce radiation exposure to organs at risks (OARs) and minimize the risk of cardiac complications. This treatment method involves stopping the breathing of patients during irradiation in order to temporarily distance the heart from the radiation field, which reduces potential cardiac risks and other complications. To identify factors that may affect the effectiveness of DIBH treatment, we analyzed the most important 5-year studies published in the PubMed database. Research shows that DIBH reduces the radiation dose to the heart and lungs. However, the effectiveness of DIBH is determined by a variety of factors, including the patient’s training, cooperation, anatomical features, age, and choice of radiotherapy technique. Additionally, cardiovascular risk factors, such as diabetes, smoking, and hypertension, can be impactful to the effectiveness and potential complications of DIBH. Moreover, if a patient has a substantial level of depression or anxiety, then they may be potentially disqualified from the DIBH treatment method. In addition to this, a lack of consent and/or fear may also disqualify a patient from DIBH treatment. Careful patient selection, comprehensive training, and optimization of treatment parameters are essential to maximize the benefits of DIBH whilst minimizing any potential side effects. DIBH enhancement techniques, such as IMRT and VMAT, also have an important role to play. The purpose of this narrative review article is to summarize the factors affecting the efficacy and side effects of DIBH in radiation therapy for left-breast cancer, with the aim of optimizing its clinical application while minimizing side effects. Patients who are likely to benefit most from DIBH are young women in good medical condition, able to cooperate with the procedure, and with smaller breasts. The increase in the estimated 10-year patient survival is significantly influenced by cardiovascular problems, so patients without diabetes and metabolic syndrome, and non-smokers, will benefit the most. An estimated 50–70% of breast cancer patients are likely to benefit from DIBH, and in the best case, it can result in a 50% reduction in the risk of cardiac problems after photodynamic therapy (PDT).

Urogeriatric thinking using the example of antiandrogen therapy for prostate cancer

The geriatric patient is defined by an age of over 75years and multimorbidity or by an age of over 80years. These patients exhibit aparticular vulnerability, which, in the incidence of side effects or complications, leads to aloss of autonomy. Treatment sequalae, once they have arisen, can no longer be compensated. It is important to recognize and document treatment requirements among geriatric patients with the help of screening instruments such as the Identification of Seniors at Risk (ISAR) and Geriatric8 (G8) scores. If a treatment requirement is identified, oncologic treatment should not be commenced uncritically but rather a focus placed on identification of functional deficits relevant to treatment, ideally using a geriatric assessment but at least based on adetailed medical history. These deficits can then be presented in astructured, examiner-independent, and forensically validated manner using special assessments. A planned treatment requires not only consideration of survival gains, but also knowledge of specific side effects and, in geriatric patients in particular, their impact on everyday life. These considerations should be compared with the patient's individual risk profile in order to prevent side effects from negating the effect of the treatment, for example by worsening the patient's self-help status. With regard to androgen deprivation in prostate cancer-which often is used uncritically-it is important to consider possible side effects such as osteoporosis, sarcopenia, anemia, and cognitive impairment in terms of apossible fall risk; an increase in cardiovascular mortality and the triggering of ametabolic syndrome on the basis of preexisting cardiac diseases or risk constellations; and to carry out acareful risk-benefit analysis.

Cluster analysis of Model for End-stage Liver Disease and European System for Cardiac Operative Risk Evaluation for predicting operative mortality after concomitant tricuspid valve surgery

ObjectivePatients requiring concomitant tricuspid surgery represent a heterogeneous cohort with significant comorbidities and varying degrees of organ and right ventricular dysfunction. However, surgeons can rely on little beyond intuition and experience when discussing operative risks. The objective of the study is to assess how the Model for End-stage Liver Disease score complements the European System for Cardiac Operative Risk Evaluation II in risk assessment. MethodsWe performed a single-center retrospective cohort study of 369 consecutive patients who underwent concomitant tricuspid valve surgery from 2011 to 2020. Multivariate analysis of factors affecting operative mortality was performed, producing 2 multivariate risk prediction models, one consisting of European System for Cardiac Operative Risk Evaluation II components and the other consisting of both European System for Cardiac Operative Risk Evaluation II components and Model for End-stage Liver Disease. The models were compared by measuring c-statistic using the Hanley-McNeil method. This was further evaluated with category-free net reclassification improvement index. K-means clustering was performed using Model for End-stage Liver Disease and European System for Cardiac Operative Risk Evaluation II values after scalar transformation as independent variables and operative mortality as the dependent variable. ResultsThe Model for End-stage Liver Disease is an independent predictor of operative mortality, with an adjusted odds ratio of 1.286 per point. Inclusion of the Model for End-stage Liver Disease improves the discriminatory power of the European System for Cardiac Operative Risk Evaluation II for operative mortality, with a difference in area under the curve of 0.128 [0.0341-0.222] (P = .0076). The net reclassification improvement index of incorporating Model for End-stage Liver Disease with European System for Cardiac Operative Risk Evaluation II was 0.959 [0.515-1.392], indicating significant improvement in risk reclassification. Cluster analysis identified a unique cohort of patients with intermediate-to-high Model for End-stage Liver Disease, not previously identified with European System for Cardiac Operative Risk Evaluation II alone, who experienced high operative mortality. ConclusionsModel for End-stage Liver Disease score as a quantifier of hepatorenal dysfunction complements European System for Cardiac Operative Risk Evaluation II in predicting operative mortality after tricuspid valve surgery.

Assessment of perioperative cardiac risk using preoperative quantitative flow ratio in patients with coronary artery disease undergoing noncardiac surgery: a retrospective cohort study.

Quantitative flow ratio (QFR) is a novel diagnostic modality for the functional testing of coronary artery stenosis, but evidence concerning the postoperative prognostic implication of QFR in noncardiac surgery (NCS) of patients with coronary artery disease (CAD) is limited. The purpose of this study was to examine the role of QFR in perioperative risk prediction in patients with coronary heart disease. This retrospective cohort study was conducted in The First Affiliated Hospital of Wenzhou Medical University between 2013 and 2022, and consecutively included patients with CAD who had undergone NCS <1 year after coronary angiography. The primary endpoint was major adverse cardiovascular events (MACEs), which were defined as a composite of cardiovascular death, nonfatal myocardial infarction, nonfatal stroke, cardiopulmonary arrest, malignant ventricular arrhythmia (MVA), congestive heart failure, and revascularization. Univariate and multifactorial Cox regression was used to identify the independent risk factors for perioperative cardiovascular events and to construct new models. The area under the curve (AUC), net reclassification improvement (NRI), and integrated discrimination improvement (IDI) were used to compare the newly constructed model with existing traditional models. Among the 929 participants enrolled (median age 68 years; 72.0% male), the primary endpoint was met in 67 (7.2%) patients within 30 days of follow-up. There was no significant difference in the incidence of the primary endpoint between patients with QFR <0.75 and those with "gray zone" lesions (0.75≤ QFR ≤0.8) (log-rank P=0.325). Patients with QFR <0.75 and those with "gray zone" lesions (0.75≤ QFR ≤0.8) had a higher incidence of primary endpoint events compared to patients with QFR >0.8. [QFR <0.75 vs. QFR >0.8: adjusted hazard ratio (HR) =20.70, P<0.001; 0.75≤ QFR ≤0.8 vs. QFR >0.8: HR =15.99, P<0.001]. The independent predictors of MACEs events within 30 days after NCS were albumin level [HR =0.92, 95% confidence interval (CI): 0.87-0.98; P=0.008], emergency surgery (HR =4.12, 95% CI: 1.66-10.23; P=0.002), and QFR ≤0.8 (HR =15.92, 95% CI: 5.96-42.51; P<0.001). In addition, adjusting the original Revised Cardiac Risk Index (RCRI) with QFR ≤0.8 as a risk factor significantly improved the risk stratification of postoperative adverse events, with the adjusted AUC rising from 0.574 to 0.740 (P<0.001). QFR ≤0.8 could independently predict perioperative cardiovascular adverse events in patients with CAD undergoing NCS and improve the predictive value of original predictive index. Gray-zone lesions (0.75≤ QFR ≤0.8) should be actively treated.

Tensor cardiography: A novel ECG analysis of deviations in collective myocardial action potential transitions based on point processes and cumulative distribution functions.

To improve clinical diagnoses, assessments of potential cardiac disease risk, and predictions of lethal arrhythmias, the analysis of electrocardiograms (ECGs) requires a more accurate method of weighting waveforms to efficiently detect abnormalities that appear as minute strains in the waveforms. In addition, the inverse problem of estimating the myocardial action potential from the ECG has been a longstanding challenge. To analyze the variance of the ECG waveforms and to estimate collective myocardial action potentials (APs) from the ECG, we designed a model equation incorporating the probability densities of Gaussian functions of time-series point processes in the cardiac cycle and dipoles of the collective APs in the myocardium. The equation, which involves taking the difference between the cumulative distribution functions (CDFs) that represent positive endocardial and negative epicardial potentials, fits both R and T waves. The mean, standard deviation, weights, and level of each cumulative distribution function (CDF) are metrics for the variance of the transition state of the collective myocardial AP. Clinical ECGs of myocardial ischemia during coronary intervention show abnormalities in the aforementioned specific elements of the tensor associated with repolarization transition variance earlier than in conventional indicators of ischemia. The tensor can be used to evaluate the beat-to-beat dynamic repolarization changes between the ventricular epi and endocardium in terms of the Mahalanobis distance (MD). This tensor-based cardiography that uses the differences between CDFs to show changes in collective myocardial APs has the potential to be a new analysis tool for ECGs.